Consumer Feedback

Consumer Feedback Form

(Please complete only if different from the consumer’s details). We appreciate that at times the person you are acting on behalf of may wish to remain anonymous. If this is the case, an investigation will not be conducted and this information will be used as constructive feedback.

Consumer:

Title:
First Name:*
Last Name:*
Address:
Suburb:
Post Code
Telephone:*
Fax:
Email:

Date of Birth:
Country of Birth:
Preferred Language:
Interpreter required:*	Yes No
Please indicate if you would be interested in attending an informal meeting with an interpreter present and we will be happy to arrange this.
	Yes No
If you have the following information, please provide: The name of the Ward , Unit, Department or Service:

The name of the treating health professional(s):

Your Southern Health Patient Number:

Person providing feedback:

Title:
First Name:
Last Name:
Address:
Suburb:
Post Code
Telephone:
Fax:
Email:

Preferred Language:
Interpreter required:	Yes No
Please indicate if you would be interested in attending an informal meeting with an interpreter present and we will be happy to arrange this.
	Yes No
What is your relationship to the Consumer?
Spouse
Partner
Parent
Child
Grandparent
Grandchild
Sibling
Guardian
Friend
Observer
Other:	Please specify:

Where was the service provided?

Casey Hospital
Cranbourne Integrated Care Centre
Dandenong Hospital
Kingston Centre
Monash Medical Centre Clayton
Monash Medical Centre Moorabbin

Community Service	Please specify site:
Mental Health Service	Please specify site:

Please provide details of your feedback including dates, times, location and outcomes.

To enable us to best meet your expectations, please advise if you would like a written response
to your feedback or if your feedback is only for our information and subsequent action:

Upon receipt of your feedback, an investigation will commence and the Consumer Liaison Officer will be in contact.
Please ensure that all of your contact numbers and address details have been completed.

If you wish to return the completed form by mail, please send it to the relevant site Consumer Liaison Officer:

Casey Locked Bag 3000 Hallam 3803 (8768 1200)	Clayton Locked Bag 29 Clayton 3168 (9594 2702)	Dandenong Hospital PO Box 478 Dandenong 3175 (9554 8078)	Kingston Centre Warrigal Road Cheltenham 3192 (9265 1309)	Moorabbin PO Box 72 East Bentleigh 3165 (9928 8584)

Or email feedback@southernhealth.org.au

Thank you for taking the time to provide us with this valued feedback.